This paper from Poland presents a case report of flubromazolam exposure. A 27-year-old male known to use psychotropic drugs was brought to hospital after being found unconscious at home. On arrival he was comatose with a Glasgow Coma Scale of 3. On exam, he was breathing at rate of 6-8/min and was intubated. He had multiple pressure sores over the right side of his body, as well as hypotonia, hypotension (80/40) and hyporeflexia. He was treated with 1500 ml normal saline. Gelofusine, and pressors. He showed no response to naloxone.

Head CT was unremarkable. Creatine kinase was 15,960 U/L and creatinine 1.53 mg/dL (reference 0.7 – 1.4.) Because the urine drug screen was positive for benzodiazepines, flumazenil was administered in doses 0.5 mg with partial improvement in level of consciousness.

A second head CT on day 3 showed “hypoxic-ischemic changes within the internal capsules bilaterally.” After the patient’s mental status improved and he could provide history, he reported ingesting flubromazolam “3 mg” purchased over the internet. Specific toxicologic testing confirmed the presence of flubromazolam in serum and urine.

The authors suggest that this case indicates that flubromazolam can cause “severe, long-lasting depression of the central nervous system with cardiorespiratory failure, complicated with brain hypoxic-ischemia changes.” Unfortunately, it’s not clear from the paper how thorough the screening was for other drugs such as fentanyl. The key take-home points are that flubromazolam may have extremely potent sedative effects, apparently shows up a benzodiazepine on the urine drug screen and is at least partially reversed by flumazenil.

Etizolam is a short-acting benzodiazepine analog with typical sedative-hypnotic properties. It is used medically in some parts of the world but not approved for use in the United States. Although not scheduled on the federal level, it is restricted in a number of states (AL, AK, GA, VA, FL, IN, MS, TX, LA.) A relatively recent case report indicates that flumazenil may readily reverse the effects of etizolam.